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Health Care Reform: Keys to Success in Launching Major Federal Health Programs

Implementing lessons learned in a post-reform environment

Michael McMullan, Senior Advisor, Deloitte Consulting LLP, joined Deloitte in 2007 after more than 30 years of Federal service, including 29 at the Centers for Medicare and Medicaid Services (CMS) and its predecessor, the Health Care Financing Administration (HCFA). Michael served in a succession of senior-level CMS/HCFA executive positions, including leading the agency on an acting basis during the transition from President Bush 41 to President Clinton. She played a major role in the implementation of the Medicare Modernization Act, which launched the Medicare Part D prescription drug program.

Political and Career Executive Alignment

Q: Michael, you’ve been a senior participant in a number of major Federal health program implementations, including the last major program launch — Medicare Part D. What do see as some of the keys to implementation success?

A: I think the first key to success is leadership, from political and career executives.

The political leaders are put in place to both foster and carry out the Administration’s agenda. They are expected to articulate clearly and consistently “what success looks like” – to set the goals and to define the parameters of success. An important example of the role of the political appointee is to drive the interpretation of the statutory language in the drafting of regulations, and in directing staff and contractors. The political leadership also manage the politics of the issues. This involves engaging Congress, affected stakeholders, advocates, grassroots organizations and others interested in promoting the success of the policy changes — and even those interested in working for the policy’s failure.

The career leadership are responsible for effecting the mandated changes. They are expected to marshal the resources, budget, staffing, information technology and more to make things happen. And, they are expected to convey the policy direction unambiguously and reliably to the organizations they serve. The importance of consistent and persistent messages about what needs to be done, why, how, by whom and when cannot be understated.

Career leadership are also expected to share purpose and accountability, assisting each other without regard to organizational lines, to enable and ensure that new policy is converted effectively into implementing operations.

Leaders Who Can Be Counted On

Q. Can you share some of your reflections about individual leadership in major program implementations?

A. Leaders need to support their staffs, to “have their backs” so to speak. When leaders ask their staffs to take a risk, such as taking a policy position forward in Departmental meetings that is different than that taken by policy analysts in other parts of the Department, the leader has to disclose his or her knowledge and backing of the position, if and as necessary. In addition, staff need to be able to rely on both the political and career leaders when they need them to be their “champions”. For example, changes in health policy can imply changes in tax policy or in other social insurance policies that are the province of other agencies. Often, these issues must be managed first “top-down” to engage the commitment of the non-health agency before staff to staff interaction can be useful.

Clarity and Certainty of Purpose

Q. Michael, how can a Federal department or agency manage implementation requirements and timelines as challenging as those in the MMA — or now, in the emerging Reform legislation?

A. To my thinking, it starts with the two Cs: clarity and certainty.

First, there must be clarity. The success of implementing any program change depends on clear and unambiguous definition of all aspects of the change. For example, the law may call for income-related premiums. The regulations and implementing policy are meant to clearly explain the reasoning behind the change (the why) and to define the path to achieve the desired outcome--for example, defining what constitutes income. The operational methods, procedures and systems are meant to define the what, how, where, when and who. Any ambiguity can lead to risk of error and rework.

There must also be certainty. Leadership must be decisive. There is often more than one way to accomplish a desired result. Leaders need to consider the alternatives, including the costs and benefits of each feasible approach, and then pick one and manage it to completion, making mid-course corrections if needed. Organizations can be paralyzed by too much analysis to find the “right answer”.

Organization and Accountability

Q. Let’s discuss some of the nuts and bolts of implementation. How can Federal agencies organize for success?

A. I’m a believer in careful and consistent program management and organization -- the classic “who is doing what by when,” including identifying dependencies and resource needs. During the Medicare Part D implementation, we had daily operations meetings to review what had been accomplished, understand any incidents or risk points, and discuss what had to be done next. This approach was taken because of the scale of the changes and the aggressive implementation deadlines. All involved leaders were at the table, and they were responsible for helping to solve any problems and to mitigate risk. The agency’s leaders were vested not only in the success of their business function, but in the success of the combined endeavor.

Final Thoughts

Q. Michael, we’ll look forward to coming back to you for more lessons learned as Reform moves from Capitol Hill to Independence Avenue (HHS Headquarters) and Security Boulevard (CMS Headquarters). But, can you share some final thoughts with us today?

A. These programs are important to all Americans. Together Medicare and Medicaid currently cover over 100 million people, or one in three Americans, and represent more than 20 percent of the federal budget. Each of us knows and cares about someone benefiting from one or both of these programs.

Changes in Medicare and Medicaid reverberate throughout the entire health care system and within the overall economy. Day one, all affected entities need to work together to identify the “best” ways to implement change – including identifying “fixes” to the legislation -- that will help lead the country to a high quality, efficient and affordable health care system.

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